QUIZ : Case based assessment of anaemia

Clinical Scenarios: Anaemia Case Quiz

Apply your understanding of MCV classification, pathophysiology, and lab interpretation to answer these anaemia questions. Choose the best answer for each case, then check your score and review the explanations.

 

1. A 66-year-old man with fatigue, microcytic anaemia (MCV 72), ferritin 80, low transferrin saturation, and elevated CRP. What is the most likely cause of his anaemia?

A. Iron deficiency anaemia
B. Thalassaemia trait
C. Anaemia of chronic disease
D. Sideroblastic anaemia
E. B12 deficiency

2. A 45-year-old vegan woman has macrocytic anaemia (MCV 118), a smooth tongue, and tingling in her hands. What mechanism explains her neurological symptoms?

A. Iron depletion causing impaired neurotransmission
B. Intramedullary haemolysis of megaloblasts
C. Failure of DNA synthesis in neuronal nuclei
D. Impaired myelin synthesis due to methylmalonic acid accumulation
E. Folate deficiency impairing spinal cord perfusion

3. A 28-year-old man with hereditary spherocytosis has anaemia, high bilirubin, high LDH, and 10% reticulocytes. Which feature best indicates bone marrow compensation?

A. Normal MCV
B. Elevated LDH
C. Spherocytes on smear
D. Reticulocyte count of 10%
E. Low haptoglobin

4. A 32-year-old woman has microcytic anaemia (MCV 72), low ferritin, and heavy menstrual bleeding. What explains the microcytosis?

A. Increased haemolysis causing small RBCs
B. Decreased DNA synthesis
C. Unbalanced globin chain production
D. Extra erythroblast divisions due to impaired haem synthesis
E. Increased erythropoietin from hypoxia

5. A 70-year-old man with chronic kidney disease has normocytic anaemia, low reticulocytes, and no signs of bleeding or haemolysis. What is the most likely cause?

A. Decreased erythropoietin production
B. Hepcidin-induced iron sequestration
C. Blood loss from uraemic gastritis
D. Reduced red cell lifespan due to uraemia
E. Haemolysis from dialysis tubing

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Answer Explanations

1. Correct answer: C. Anaemia of chronic disease
Although the MCV is low (suggesting microcytosis), the ferritin is normal to high and transferrin saturation is low. This combination points toward anaemia of chronic disease (or anaemia of inflammation), not iron deficiency. Inflammatory cytokines (especially IL-6) increase hepcidin, which blocks iron absorption and traps iron in macrophages. As a result, iron is present but unavailable for erythropoiesis. In contrast, iron deficiency anaemia would show low ferritin. Thalassaemia typically shows a normal or raised iron profile with a family history and target cells.

2. Correct answer: D. Impaired myelin synthesis due to methylmalonic acid accumulation
Vitamin B12 is essential not only for DNA synthesis but also for the conversion of methylmalonyl-CoA to succinyl-CoA. In deficiency states, methylmalonic acid accumulates and disrupts myelin sheath formation in the central and peripheral nervous system, leading to neurological deficits such as paresthesias and impaired proprioception. This mechanism is distinct from folate deficiency, which may cause similar macrocytosis but does not cause neurological symptoms. Thus, the presence of neurological signs helps distinguish B12 from folate deficiency.

3. Correct answer: D. Reticulocyte count of 10%
A high reticulocyte count is the most direct indicator that the bone marrow is responding appropriately to anaemia — in this case, due to haemolysis from hereditary spherocytosis. LDH, bilirubin, and haptoglobin abnormalities support the diagnosis of haemolysis, but reticulocytosis confirms marrow compensation. Spherocytes are characteristic on smear but are a diagnostic feature, not a sign of compensatory response. Reticulocyte response is essential to assess marrow function.

4. Correct answer: D. Extra erythroblast divisions due to impaired haem synthesis
In iron deficiency anaemia, the lack of iron leads to impaired haemoglobin synthesis. To maintain intracellular haemoglobin concentration, erythroblasts undergo extra mitotic divisions — resulting in smaller-than-normal red cells (microcytosis). This is a compensatory response to reduced haem content. Other options like unbalanced globin chain production (thalassaemia) or decreased DNA synthesis (seen in macrocytic anaemia) do not explain the mechanism in this common scenario.

5. Correct answer: A. Decreased erythropoietin production
Chronic kidney disease leads to reduced production of erythropoietin (EPO), which is essential for stimulating red cell production in the bone marrow. As a result, patients develop a normocytic anaemia with low reticulocyte counts, indicating underproduction. While uraemia may mildly reduce red cell lifespan or cause gastrointestinal bleeding, these are not the primary drivers of anaemia in CKD. Hepcidin excess can contribute, but the dominant mechanism is inadequate EPO.

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